The effect of REDV/TiO2 coating coronary stents on in-stent restenosis and re-endothelialization

Coatings for Cardiovascular Stents-An Up-to-Date Review

Cardiovascular diseases (CVDs) increasingly burden health systems and patients worldwide, necessitating the improved awareness of current treatment possibilities and the development of more efficient therapeutic strategies. When plaque deposits narrow the arteries, the standard of care implies the insertion of a stent at the lesion site. The most promising development in cardiovascular stents has been the release of medications from these stents. However, the use of drug-eluting stents (DESs) is still challenged by in-stent restenosis occurrence. DESs' long-term clinical success depends on several parameters, including the degradability of the polymers, drug release profiles, stent platforms, coating polymers, and the metals and their alloys that are employed as metal frames in the stents. Thus, it is critical to investigate new approaches to optimize the most suitable DESs to solve problems with the inflammatory response, delayed endothelialization, and sub-acute stent thrombosis. As certain advancements have been reported in the literature, this review aims to present the latest updates in the coatings field for cardiovascular stents. Specifically, there are described various organic (e.g., synthetic and natural polymer-based coatings, stents coated directly with drugs, and coatings containing endothelial cells) and inorganic (e.g., metallic and nonmetallic materials) stent coating options, aiming to create an updated framework that would serve as an inception point for future research.

Blood-repellent and anti-corrosive surface by spin-coated SWCNT layer on intravascular stent materials

Despite intravascular bare metallic stents (BMS) being indispensable products in cardiovascular surgery, they face in-stent restenosis (ISR), resulting in stent failure or secondary surgical operation necessity. Accumulation or corrosion processes are key factors that promote ISR development in a vascular pathway, including an intravascular stent. The ISR can be inhibited by increasing the blood-repellency, and electrochemical corrosion resistance features using surface modification techniques on intravascular stent materials. In this study, Single-Walled Carbon Nanotube (SWCNT) structures were deposited using the spin-coating method on stent specimens made of 316L, 316LVM, CoCr-alloy, and Ti-alloy. Hydrophobicity and blood-repellency functions of coated and uncoated specimens were analysed by the Contact Angle (CA) values for distilled water (DIW), glycerol, blood plasma, and total-blood droplets using a computer-controlled goniometer system. Using a potentiostat, the electrochemical corrosion resistance features were analysed from obtained Electrochemical Impedance Spectroscopy (EIS) and Tafel curves in 37 °C Simulated Body Fluid (SBF) mimicking the human blood plasma. Due to the CA values below 90°, the repellency limit for hydrophobicity and blood-repellency, bare specimens performed hydrophilic and blood-philic features. However, SWCNT coating increased the repellency functions to 95° for DIW and 96° for total blood. The electrochemical corrosion resistance analysis showed that 1.433 kΩ cm² polarization resistance and 1.07 kΩ cm² electrochemical impedance of bare specimens increased to 142.8 kΩ cm² and 141.3 kΩ cm² by SWCNT coating. These corrosion resistance enhancements led to ratios of 78.13% inhibition in the corrosion rate and mass loss rate per year for SWCNT-coated 316LVM specimens. The maximum inhibition efficiency was observed for SWCNT-coated 316LVM specimens with a ratio of 87.92%. Obtained results indicate that SWCNT coating of the intravascular stents can inhibit the ISR risks of the BMS group.

Evaluation of Biocompatibility of 316 L Stainless Steels Coated with TiN, TiCN, and Ti-DLC Films

In this study, TiN, TiCN, and Ti-diamond-like carbon (Ti-DLC) films were coated on 316 L stainless steel (AISI 316 L) substrate surface by physical vapor deposition. The biocompatibility of the three films (TiN, TiCN, and Ti-DLC) and three metals (AISI 316 L, Ti, and Cu) was compared on the basis of the differences in the surface morphology, water contact angle measurements, CCK-8 experiment results, and flow cytometry test findings. The biocompatibility of the TiN and TiCN films is similar to that of AISI 316 L, which has good biocompatibility. However, the biocompatibility of the Ti-DLC films is relatively poor, which is mainly due to the inferior hydrophobicity and large amount of sp2 phases. The presence of TiC nanoclusters on the surface of the Ti-DLC film aggravates the inferior biocompatibility. Compared to the positive Cu control group, the Ti-DLC film had a higher cell proliferation rate and lower cell apoptosis rate. Although the Ti-DLC film inhibited cell survival to a certain extent, it did not show obvious cytotoxicity. TiN and TiCN displayed excellent performance in promoting cell proliferation and reducing cytotoxicity; thus, TiN and TiCN can be considered good orthodontic materials, whereas Ti-DLC films require further improvement.

Surface engineering at the nanoscale: A way forward to improve coronary stent efficacy

Coronary in-stent restenosis and late stent thrombosis are the two major inadequacies of vascular stents that limit its long-term efficacy. Although restenosis has been successfully inhibited through the use of the current clinical drug-eluting stent which releases antiproliferative drugs, problems of late-stent thrombosis remain a concern due to polymer hypersensitivity and delayed re-endothelialization. Thus, the field of coronary stenting demands devices having enhanced compatibility and effectiveness to endothelial cells. Nanotechnology allows for efficient modulation of surface roughness, chemistry, feature size, and drug/biologics loading, to attain the desired biological response. Hence, surface topographical modification at the nanoscale is a plausible strategy to improve stent performance by utilizing novel design schemes that incorporate nanofeatures via the use of nanostructures, particles, or fibers, with or without the use of drugs/biologics. The main intent of this review is to deliberate on the impact of nanotechnology approaches for stent design and development and the recent advancements in this field on vascular stent performance.

Endothelial Cell-Mediated Gene Delivery for In Situ Accelerated Endothelialization of a Vascular Graft

As an urgently needed device for vascular diseases, the small-diameter vascular graft is limited by high thrombogenicity in clinical applications. Rapid endothelialization is a promising approach to construct an antithrombogenic inner surface of the vascular graft. The main bottleneck for rapid endothelialization is the adhesion, migration, and proliferation of endothelial cells (ECs) in situ of the small-diameter vascular graft. Herein, we innovatively fabricated an intelligent gene delivery small-caliber vascular graft based on electrospun poly(lactic acid-co-caprolactone) and gelatin for rapid in situ endothelialization. The graft surface was co-modified with EC adhesive peptide of Arg-Glu-Asp-Val (REDV) and responsive gene delivery system. REDV can selectively adhere ECs onto the graft surface; subsequently, the overexpressed matrix metalloproteinase by ECs can effectively cleave the linker peptide GPQGIWGQ-C; and finally, the gene complexes were intelligently and enzymatically released from the graft surface, and thereby, the gene can efficiently transfect ECs. Importantly, this enzymatically releasing gene surface has been proven to be safe and temporarily stable in blood flow owing to the biotin-avidin interaction to immobilize gene complexes on the inner surface of vascular grafts through the GPQGIWGQ-C peptide linker. It has the advantage of specifically adhering the ECs to the surface and smartly transfecting them with high transfection efficiency. The co-modified surface has been demonstrated to accelerate the luminal endothelialization in vivo, which might be attributed to the synergistic effect of REDV and effective gene transfection. Particularly, the intelligent and responsive gene release surface will open a new avenue to enhance the endothelialization of blood-contacting devices.

Bioclickable and mussel adhesive peptide mimics for engineering vascular stent surfaces

Thrombogenic reaction, aggressive smooth muscle cell (SMC) proliferation, and sluggish endothelial cell (EC) migration onto bioinert metal vascular stents make poststenting reendothelialization a dilemma. Here, we report an easy to perform, biomimetic surface engineering strategy for multiple functionalization of metal vascular stents. We first design and graft a clickable mussel-inspired peptide onto the stent surface via mussel-inspired adhesion. Then, two vasoactive moieties [i.e., the nitric-oxide (NO)-generating organoselenium (SeCA) and the endothelial progenitor cell (EPC)-targeting peptide (TPS)] are clicked onto the grafted surfaces via bioorthogonal conjugation. We optimize the blood and vascular cell compatibilities of the grafted surfaces through changing the SeCA/TPS feeding ratios. At the optimal ratio of 2:2, the surface-engineered stents demonstrate superior inhibition of thrombosis and SMC migration and proliferation, promotion of EPC recruitment, adhesion, and proliferation, as well as prevention of in-stent restenosis (ISR). Overall, our biomimetic surface engineering strategy represents a promising solution to address clinical complications of cardiovascular stents and other blood-contacting metal materials.

Conjugating heparin, Arg–Glu–Asp–Val peptide, and anti-CD34 to the silanic Mg–Zn–Y–Nd alloy for better endothelialization

Magnesium alloy is generally accepted as a potential cardiovascular stent material due to its good mechanical properties, biocompatibility, and biodegradability, and has become one of the research hotspots in this field. However, too fast degradation rate and delayed surface endothelialization have been the bottleneck of further application of magnesium alloy stent. In this study, we selected Mg–Zn–Y–Nd, a kind of biodegradable magnesium alloy for cardiovascular stent, and passivated its surface by alkali heat treatment and silane treatment to improve the corrosion resistance, subsequently conjugated Arg–Glu–Asp–Val (REDV) peptide and anti-CD34 to promote endothelial cells adhesion and capture endothelial progenitor cells respectively, further improving surface endothelialization. In addition, the heparin was also immobilized to the Mg–Zn–Y–Nd surface for the consideration of anti-coagulation and anti-inflammation. Systematic material characterization and biological evaluation show that we have successfully developed this composite surface on Mg–Zn–Y–Nd alloy, and achieved multiple functions such as corrosion resistance, promoting endothelialization, and inhibiting platelet/macrophage adhesion.

Study of functional drug-eluting stent in promoting endothelialization and antiproliferation

Drug-eluting stents have been widely used in the clinic because of their impressive ability to reduce restenosis. However, the conventional biodegradable polymers used for drug-loaded coatings undergo bulk erosion, which can induce internal catalysis, resulting in a high local acidity during the degradation process and unfavorable side-effects. Herein, poly(1,3-trimethylene carbonate), a surface eroding biodegradable polymer, was chosen as a drug-loaded coating for cardiovascular stents. We modified both sides of the stent to simultaneously promote re-endothelialization at the inner layer and reduce restenosis at the outer layer, using a titanium oxide (Ti-O) film as the inner layer and a Ti-O film/drug coating as the outer layer. In vitro and in vivo results indicated that the Ti-O film accelerated endothelial cell growth and re-endothelialization, and the drug coating inhibited platelet adhesion, activation, and aggregation, smooth muscle cell proliferation, and significantly reduced neointimal hyperplasia. Therefore, this novel stent may have potential as a cardiovascular stent to treat patients with coronary artery stenosis.

In vitro evaluation of vascular endothelial cell behaviors on biomimetic vascular basement membranes

Vascular basement membrane (VBM) is a thin layer of fibrous extracellular matrix linking endothelium, and collagen type IV (COL IV) is its main composition. VBM plays a crucial role in anchoring down the endothelium to its loose connective tissue underneath. For vascular grafts, constructing biomimetic VBMs on the luminal surface is thus an effective approach to improve endothelialization in situ. In the present work, three types of polycaprolactone (PCL) membranes were produced and characterized through cell counting kit-8 (CCK-8) assay, adhesion force and elastic modulus test to examine the influence of fiber diameter and membrane composition on vascular endothelial cell (EC) behaviors. The PCL membranes with finer fibers of 54.77 nm (PCL-54) could biomimic the nanotopography of VBMs more efficiently than 544.64 nm (PCL-544), and they were more suitable for Pig iliac endothelium cells (PIECs) adhesion and proliferation, meanwhile, inducing higher elastic modulus and adhesion force of PIECs. On this foundation, we further immobilized COL IV onto PCL-54 (PCL-COL IV) to biomimic VBMs compositionally. Results showed that PIECs on PCL-COL IV exhibited the highest viability and proliferation. Besides, quantitative data indicated that the elastic modulus of the PIECs on PCL-COL IV (4441.00 Pa) was as two times higher than that on PCL-54 (2312.26 Pa), and the adhesion force grew to 1120.99 pN from 673.58 pN of PIECs on PCL-54. In summary, the PCL-COL IV membranes show high similarity with the native VBMs in terms of structure and composition, suggesting a promising potential for surface modification to vascular grafts for improved endothelialization.

Direct surface modification of metallic biomaterials via tyrosine oxidation aiming to accelerate the re-endothelialization of vascular stents

Rapid in-situ re-endothelialization of coronary stents is one of the most effective approaches to inhibit late thrombosis and restenosis. Strut surfaces allowing excellent adhesion and migration of endothelial cells and endothelial progenitor cells may accelerate in-situ re-endothelialization. Here, a well-known endothelial cell adhesive peptide, Arg-Glu-Asp-Val (REDV), was directly immobilized onto metallic surfaces by means of single-step tyrosine oxidation with copper chloride (II) and hydrogen peroxide, which we recently reported as a new biomaterial modification technique. REDV immobilization on a 316L stainless steel plate improved endothelial cell adhesion and effectively suppressed platelet adhesion in vitro. In addition, a Co-Cr stent immobilized with Ac-Tyr-Gly-Gly-Gly-Arg-Glu-Asp-Val (Y-REDV) was implanted into a rabbit abdominal aorta. On 7 days postimplantation, 80% of the strut surface of the Y-REDV-immobilized stent was covered by a thin neointimal layer and was similar in appearance to native endothelium. Restenosis and late thrombosis were not observed in the Y-REDV-immobilized stent for 42 days. These findings suggest that direct immobilization of Y-REDV peptide onto metallic biomaterials by tyrosine oxidation is effective for promoting in-situ re-endothelialization in vascular stents. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 106A: 491-499, 2018.